Wednesday, December 30, 2009

I moved my office yesterday. As fate would have it, the final piece of mail I received at my old address was a notice from Medicare informing me that I needed to update them if there were any changes in my practice, for example, a change of address. It told me where to go (on the internet, that is).

If I understand the directions right (and do feel free to help me out here) CMS-8551 is the form for me:

Additional Information Physicians can apply for enrollment in the Medicare Program or make a change in their enrollment information using either: 1. Have a National Plan and Provider Enumeration System (NPPES) User ID and password to use Internet-based PECOS. • For security reasons, passwords should be changed periodically, at least once a year. • For information on how to change a password, go to the NPPES Application Help page and select the “Reset Password Page” on the NPPES Application Help page. 2. Go to PECOS to complete, review, and submit the electronic enrollment application via PECOS. 3. Print, sign, and date the two-page Certification Statement and mail it with all supporting paper documentation to the Medicare contractor within seven days of the electronic submission. NOTE: A Medicare contractor will not process an Internet enrollment application without the signed and dated two-page Certification Statement and the required supporting documentation. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed two-page Certification Statement that is associated with the Internet submission. Physicians who are enrolled in the Medicare Program, but have not submitted the CMS-855I since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the CMS-855I) as an initial application when reporting a change for the first time. If a physician has any questions about reporting a change, the physician should contact his or her designated Medicare contractor in advance of submitting the CMS-855I.(Note, I deleted the Medicare web addresses from the body of the text I copied)

Okay, so 221 downloadable forms, and the form for change of address is the CMS-8551. No prob, I'm on it. PECOS. What are PECOS? I know what pesos are, but PECOS? So form CMS-8551, downloaded for my change of address is 27 pages long. What would it take to get Medicare to have 222 downloadable forms, with the 222nd form being a one-page change of address form.

Tuesday, December 29, 2009

I moved today! My new office is wonderful. Roy made fun of me because I went to 4 paint stores and 'test drove' 8 different shades of tan, finally settling on Shabby Chic (tan). It's perfect and it goes nicely with the "mushroom" colored carpeting that was being installed at 4 pm yesterday.

So I'm excited. Same furniture. Same Dinah. Mostly the same pics on the wall. Somehow, though, I feel like I got something big out of the way.

Wednesday, December 23, 2009

It's that time of year when blogging gets a little lame.
I'm off to pack up my old office, feeling a bit sore after two days of trying to keep up with my high school athlete kid....I'm feeling a little out of shape these days, and so after a day on the ski slopes and an hour or so being yesterday's squash partner, well, I'm not moving so fast today! And my college kid has finally made it home after days of exams.... arrived for a month with a small suitcase containing his XBox and some dirty crumpled clothes, still refusing to be my Facebook friend.

Clink is off to the cold to ski and climb things. Roy....he was in the mall last night... who knows what he's up to? His new puppy seems to have a better designer wardrobe than I do.

So we'll blog or we won't, but if we don't, please know we're wishing you the best for a joyous holiday season and a safe, happy, and (mentally & physically) healthy new year!

Sunday, December 20, 2009

Today I was friended by psychiatrist friend I haven't seen in a while. She's in her 80's and has always been pretty technologically savvy. I told one of my teenagers, who has met this friend in real life, and she (the teenager) told me she didn't want to hear it! Huh, you aren't interested in my Facebook life?

"People don't talk about what happens on Facebook."

Huh? Neat stuff happens on Facebook, why can't I talk about it?

Well, I got an earful. You talk about what happens on FB, because then it's like you don't have a real life, and people will think you're pathetic, and this will push away the real people in your life who now think you're rather dismal and all you have to talk about is your virtual life because you have no real life to talk about, and then you'll have less people in your real life and you'll need Facebook even more, and it's a vicious cycle.

Friday, December 18, 2009

It's my first night of vacation! I saw my last patient today and then started pulling the pictures off the walls in anticipation of my move. I ran over to see the new place, and it still needs insulation (it's on the floor), paint, and carpet. And doorknobs might be nice.

So we're expecting quite the snowstorm here. I'll let you know how it goes tomorrow, but the current forecast is for up to 20 inches. It didn't take me long to float from the weather to the health section of the New York Times, and here's an article by Leslie Alderman about generics versus name brands.

Are generics as good as name brands? I don't have any studies, I'm purely running on anecdotes, but this is my thinking: Usually. When I was resident, I learned that 15% of the time (and this isn't science, I don't think, I believe it's someone else's anecdote) generic nortryptiline doesn't work when name brand Pamelor does. So I've always asked patients to start with Pamelor....I don't use it much anymore....because who wants to spend 6-8 weeks on a medication trial and have someone not respond only to realize they were in that small group of patients who are sensitive to the brand.

Other meds: I've had a handful of people complain about generic Prozac-- fluoxetine. It's not as effective for them, or they have more side effects. Alderman's article talks about Wellbutrin XL and I didn't even realize that the XL form now has a generic. Sometimes people want the name brand.

So what do I do when a patient specifically requests the name brand? I give it to them: if they are right, then they are right. And if they simply believe that they won't respond to the generic, because there are people who say "Generics don't work on me," well, then there's power to such beliefs, and I just want my patients to get better.

Tuesday, December 15, 2009

With unemployment driving foreclosures nationwide, a quarter of those polled said they had either lost their home or been threatened with foreclosure or eviction for not paying their mortgage or rent. About a quarter, like Ms. Newton, have received food stamps. More than half said they had cut back on both luxuries and necessities in their spending. Seven in 10 rated their family’s financial situation as fairly bad or very bad.

But the impact on their lives was not limited to the difficulty in paying bills. Almost half said unemployment had led to more conflicts or arguments with family members and friends; 55 percent have suffered from insomnia.

“Everything gets touched,” said Colleen Klemm, 51, of North Lake, Wis., who lost her job as a manager at a landscaping company last November. “All your relationships are touched by it. You’re never your normal happy-go-lucky person. Your countenance, your self-esteem goes. You think, ‘I’m not employable.’ ”

A quarter of those who experienced anxiety or depression said they had gone to see a mental health professional. Women were significantly more likely than men to acknowledge emotional issues.

Monday, December 14, 2009

Roy has Electronic Medical Records on his mind lately and if you'd like to hear him, oh, he'd love to tell you his thoughts. Or read his last post here. I'm still not sure how I feel about Electronic Records-- I worry about confidentiality and the propagation of incorrect information.

So why are medical records oh so important? What about making other important things into Electronic Records so that information can be shared and referred to? Never mind Electronic Medical Records, what I need are Electronic Hair Records!

Hair, you ask? Hair! Let me tell you about my hair. I am a user of hair chemicals and it's no picnic when I'm away and need an emergency procedure. What could electronic hair records do?Well there was the two year period where I saw a very nice hair dresser and somehow my hair was always too light. I had her switch chemical brands, but to no avail. Finally, I switched salons, and my hair is darker. There was the time that I wanted to have a chemical procedure done with a gift certificate at another salon and was told that if I'd had a certain process done previously, my hair might break off or fall out. If there was an EHairR, my hair dresser could have checked this-- instead we had to call my home salon and determined that it wasn't safe....my hair, indeed, could have fallen out. Oh, and because of all the processes, I must use a sulphate-free shampoo. No EHairR: I have to be the one to remind the shampoo person of this issue each and every time. No one even asks.

So what could an Electronic Hair Record do?

Keep track of all chemical processes, brand names, colors, and dates of application.

Coordinate dates of chemical processes to prevent interactions.

Include panoramic photos of all haircuts so that patron could walk in and say, I liked the way it looked after the last cut and that cut could be reviewed.

Include standardization of lengths: bangs to a half inch above the eyebrows would be precise.

For those with thinning hair or balding, track hair loss.

Include computer generated growth photos to help schedule haircuts with important life events.

Download onto a iPhone app so the patron could, at last, own their own EHairR!

Sunday, December 13, 2009

A group of internet friends (what do you call people you know only via the net? peeps? tweeps? there have to be better words) have been talking over the last couple weeks (via Google Wave and also on Posterous and Skype about what we've been calling "Flower" or #hcflower on Twitter) about the changes that need to occur to reform health care. One of the revolutionary -- and critical -- changes needed is the recognition that patients need access to their health data. They not only have a right to access it, but should own it and be able to license access to it. For a particular purpose. For a particular period of time. To particular individuals or organizations (my doctor, my hospital, my insurance company, my wife, my tweeps).

But that is not being much discussed in Washington.

One of these friends is Gilles Frydman, who also founded ACOR. Click on his post on Open Streams and Fax Machines below.

"Close to $2.5 trillions have been spent on health care since President Obama announced his decision to reform the health care system. A year later, as expected, all the talk in Washington remains about:

Have you heard ANY politician talk about patient/individuals empowerment in relation to health care reform? I have not! Health care reform is still 100% about reimbursement reform and 0% about social innovation. No surprise when individuals so often experience dehumanizing events when they interact with the medical system." [more]

"Assigning textual tags to an image is an important task because tags are needed for things like image search. When you search for an image of a “cat,” modern search engines can only identify an image as containing a cat if the tag “cat” is associated with it.

Having people tag images by hand is an onerous task. Shenoy and Tan of Microsoft Research developed a way to tag images automatically by reading people’s brain scans while they look at images. The people did not even have to specifically think about trying to tag the image; they merely had to passively observe it." [more]

Wednesday, December 09, 2009

Displacement is a defense mechanism that occurs when one refocuses an emotion, like anxiety or anger, onto a benign, less-threatening object than the object it is intended for. Kicking the dog is the classic example, with the assumption that it's safer to kick the dog than it is to kick the boss.

Moving is, for me, both an exciting event and a stressful one. Invariably, I deal with it by focusing my energies on worrying about something that is a bit ridiculous. When I finished med school and was leaving my life as a student to become an intern, I worried about finding enough boxes to pack in. When I finished my internship and was getting ready to move out of state and begin residency training in psychiatry, my husband pre-empted my obsession: he went out and bought boxes. (Who buys boxes?) I worried, instead, that there wouldn't be enough shelf space in my new kitchen-- I'd seen the apartment once on a whirlwind tour of apartments and couldn't remember the details. The funny part is that the kitchen we were leaving in New York City measured exactly two-feet by five-feet (yes, I measured it) and had only a single cabinet and no shelves. I'm not sure what I thought I owned that needed so much shelf space, but I arrived in town here to discover that both sides of a long kitchen were lined with shelves, cabinets, and drawers-- more than I would ever fill.

So I'm getting ready to relocate my practice. I'm moving 3 miles and I'm moving into a space that's being tailored to my needs. Oh, but I'm moving one of me into a space with 5 offices: I need some buddies. A couple of people have expressed interest in joining me, and this is exciting! Only I'm not showing any prospective sub-letters the space right now because it a construction zone, full of debris and equipment. Somehow, wandering around the space and muttering "put a door here, move a wall there, change these lights..." came pretty easily. Pick a color for the walls...well, that's where all my angst got displaced to.

Tan. I want tan walls. It's a warm color, it's neutral, it'll look nice with my red chairs. I called a decorator, she couldn't come soon enough. I advertised on a listserv for an emergency decorator, I got a few suggestions and a friend with good taste came to my rescue. She picked a carpet and a paint. The paint went on kind of yellowy. The carpet wasn't available. She picked another carpet ("Mushroom"...do I want mushroom? No one involved was asking me any more). She picked paint. Taupe. Gorgeous. It went up purple. I've been to 4 paint stores and have bought 6 sample quarts. The back of my basement door looks like a an artist's palette. The office looks like...I don't what it looks like, with variations of pinky tans and purply tans and yellowy tans all up all over the place. The property manager has taken to yelling at me "I'll come pick you a color!"
So I've got it, finally: the walls will be Shabby Chic (thank you Benjamin Moore).

Tuesday, December 08, 2009

Teenagers. They should be considered their own species (--note, no one asked me).

Perri Klass, M.D. has a nice piece in the New York Times about assessing teens for depression and suicide, "18 and Under--Asking the Hard Questions." It's mental health from the perspective of a pediatrician, and I like that she's thoughtful about the issues.

Here's an excerpt:

And before you get to the S’s, there is the E for emotion, which, Dr. Ginsburg said, should be much more than screening for depression. “If you start by asking boys if they’re depressed or sad, most boys will deny that,” he told me. “If you start by saying, ‘So, are you stressed out?’ — every boy, no matter how big and strong, every girl, no matter how much she wants to portray herself as being in control, will admit to stress.”

Markers for depression may help identify adults at risk for suicide, but they are not a reliable way to screen adolescents. “Only about half of kids who kill themselves are depressed in the way that we think about depression — sad, not taking care of themselves, not sleeping or sleeping too much, not eating or eating too much,” Dr. Ginsburg said. The other half may be impulsive, angry, disappointed, trying to get even.

Dr. Shain said adolescents often changed their ideas and their plans. So an assessment has to go beyond the feelings of the moment to include thoughts they have had, dangerous ways they have behaved and the important questions of intent and ambivalence.

If a teenager does acknowledge thinking about suicide, there are many more questions to be asked. Dr. Lydia A. Shrier, director of clinic-based research on adolescent and young-adult medicine at Children’s Hospital Boston, said some young people chronically struggled with these issues.

Monday, December 07, 2009

In my private practice, I give people directions on the phone: how to get to my office, where to park, what to bring, what to do about their health insurance, yadayadayada.... It's a lot of information. I don't have forms, except for an Authorization to Obtain/Release Psychiatric Information, and I give people a single sheet of Office Policies with my cancellation policy and how to reach me: cell phone, home phone.

No other forms, and a few times I've wished I had an emergency contact or some piece of information I didn't have at my fingertips. So I'm moving this month and I'm re-thinking my professional life. Mostly, I've funneled my anxiety into the decor--I'm now on my 5th and 6th quarts of sample paint. Why doestaupe look purple when you put it on the wall?

Oh yeah, I was talking about forms. So I'm going to try sending out a few sheets of information before the first appointment: directions, where to park, what to expect, what to bring, and a form requesting some basic contact info. I've been wondering what other people do, and so I've been surfing other shrinks' websites to see what they do: a lot of them have their forms up, some even have their fees listed. This is interesting.

So the forms thing also gets interesting. Some people have really extensive, all-inclusive, no-issue-left-unaddressed forms. One doc asks people to circle the name of any psychotropic they've ever been on, and he lists the name of every psychiatric medication. Here's the list:

Other shrinks have fewer forms, but still post some very interesting stuff. One has photos of herself in a red leather skirt on an analyst's couch (I thought it was an ad for a TV show about a psychiatrist!), another includes his resume and mentions he was an Eagle Scout.

Okay, so tell me if you have a shrinky website, I'd love to look at it. And since I've always just asked people questions and never asked them to fill out forms, tell me how you feel about forms, both from the doc's point of view, and also from the patient's perspective. Thank you!

Oy, the Ravens, they aren't doing so well. I think they got the wrong forms.

Friday, December 04, 2009

When I was in medical school I was fascinated by neuroanatomy and neuroscience. I enjoyed reading popular science books like Broca's Brain and The Three Pound Universe. I liked reading about the classic clinical cases studies that taught us a lot about how the brain works---cases like Phineas Gage, the Nineteenth Century railroad foreman whose brain injury revealed the purpose of frontal lobes, or the case of H.M., the man whose temporal lobectomy taught us about the how memory works.

Patient H.M. had parts of both his temporal lobes removed in order to treat a seizure disorder. After the surgery he was unable to form new memories at all, and he became one of the most-studied subjects in the field of neuropsychology. From H.M. we learned that there are two types of memory, declarative and procedural memory. Declarative memory is the what we use when we learned facts. Procedural memory is what we use when we learn how to do things, like brush our teeth or ride a bike. H.M's temporal lobectomy destroyed his declarative memory, but his procedural memory was left intact.

I'm bringing this up now because of an article in Wednesday's New York Times, "Dissection Begins on Famous Brain". Patient H.M., whose name we now know is Henry Molaison, died last year and donated his brain to a neuroscience project at M.I.T. They are in the process of sectioning his brain to learn more about what went wrong with it. There is even a web site, the Brain Observatory, where you can watch the sectioning as it happens.

I read the story and checked out the sectioning web site, but my reactions are mixed. As a psychiatrist it's fascinating to see that we can study a lesion from an individual patient all the way down to the microscopic level, but as a human being it leaves me feeling rather sad for this guy. It was noble of him to donate his brain, and years of his life, to science but on the other hand I can't help wondering if he ever just wished people would leave him alone.

Thursday, December 03, 2009

Here's a story about a supermax facility in Illinois. Apparently efforts are being made to improve mental health services to these control unit inmates, some of whom have been insolitary confinement for up to ten years.

They're getting a lot of service: group and individual counselling, psychiatric treatment and recreational activities. And they've had some serious behavior problems---109 of the 247 inmates are there because they committed new criminal offenses while in prison, includingstabbing correctional officers and murder.

To me the story isn't interesting because of the mental health care issues or because of the nature of the inmates----that's pretty much old stuff to me. What I always think is fascinating are the comments left by the readers. Some people think the inmates are so mentally illthat they shouldn't be locked up in spite of their repeated violent offenses. Others call them "animals" or worse, and want them all to be killed. Stories like this reveal more about the readers, and about society in general, than about the patients I treat or the system Iwork in. As long as there is this level of hysteria and extremism we as a society have trouble addressing the needs of our offenders realistically.

Wednesday, December 02, 2009

It used to be, in the good old days, that people lived life sequentially. You moved forwards. Not completely-- we take pictures so we can look back and remember, and save a bit of the present for the future when it will then be the past. We go to class reunions, save mementos of special occasions, hold on to love letters, treasure bits and pieces of the past, and here and there, we reconnect with someone from another time and place. It grounds us, forms some connection, gives us a sense of history and meaning.

And then was the Internet and we all Googled and Oogled and found lost lives and reconnected via Email.

And there was Facebook and the past and the present are now one and the same. We live stuck in time and I'm never sure which direction I'm going. Reconnection is the rule-- I have Facebook friends from kindergarten. A few years back, I got an email from my prom date-- "Remember me, the guy in the tux 25 years ago?" Okay, it was fun. Last night we chatted on Facebook. He landed where I thought he would land (sequencing DNA, if you must know). I then found a page for my elementary school. The school name was spelled wrong and the street name was also off, but the photo...no doubt it was my elementary school. The FB members were talking about the teachers, trying to remember them all. I'd forgotten about Mr. Firestone, the 4-6th grade gym teacher. But they forgot a lot of other teachers-- I was tempted to join so that Mr. Trogler wouldn't be lost-- but did I really want to? Shouldn't I be spending time on things that move me forward? There's that book to write (oy)...dogs to walk...laundry to fold...endless paint swatches to try for my new office. Instead, here I am chatting with my prom date, thinking about Mr. Shannon --my 5th grade teacher who had us write about an invention. My invention: a machine that would type what you said-- he told me it could never be done. That and growing hair on a bald head...oh for Mr. Shannon to have met Rogaine. The things I remember. I know what's happening in the lives of my friends far and wide (Laurie's mom read to her son last night, photo on Facebook; Joan's foot hurts; my second cousin unwittingly set her alarm an hour early and didn't realize this until she was outside waiting for her ride at 6 AM...). Connection is good, but when does it become too much?

I've been told that I have a tendency to repeat stories. I've been told that several times, usually with the implication that I'm starting to "lose it". Finally, in today's New York Times there's an article that proves I'm normal.

According to "Story? Unforgettable. The Audience? Often Not.", researchers have demonstrated that there's a difference between "source memory" (a memory of where you learned certain facts) and "destination memory" (the memory of the person you told a fact to). The story talks about a study done by two Ontario psychologists. They took a group of college students and gave them a list of 50 facts. Half of the students were told to read the list quietly to themselves and were shown a picture of a celebrity immediately afterward. The other test subjects were told to pretend that they were "telling" the facts to a picture of a celebrity. All of the subjects were then tested to see if they could remember which celebrity-fact pairs they were given. Students had significantly worse memories for the celebrities they were "talking" to than for the celebrity they were "learning" from.

The psychologists say this is normal, because when someone tells a personal story they are self-involved in the process and less able to attend to the person they are speaking to---making the audience forgettable, in a sense. This also serves an adaptive function:

"The tendency to blank on who-I-told-what may in fact reflect the workings of a healthy memory. Psychologists have found evidence that when people reset a password or a new phone number for an old friend, their brain actively suppresses the out-of-date digits. The old numbers are a competing memory, and potentially confounding."

In other words, if you spend a lot of memory power keeping track of what you've told and to whom, you're going to forget more things overall.

So there. I'm going to pass this little item along to the person who teases me about my repetitive personal anecdotes. Or maybe I've sent this to him already, I don't remember.

Tuesday, December 01, 2009

I've been following the story of Maurice Clemmons, the suspect wanted for the killing of four police officers in Seattle. I don't have any connection to the case, but his story is familiar to me from thousands of inmates like him I've met over the years.

In addition to the media reports, I reviewed the parole and clemency documentation published here.

Here's what strikes me about the case:

Clemmons was a repeat offender who committed new crimes every few months until he turned eighteen. The longest break in his criminal activity was the eleven years that he was in the Arkansas prison system. We don't know what he was involved in before that because juvenile records are generally sealed.

He was already under court supervision when he was convicted of the robbery and theft that sent him to prison in 1990. Even though he was only about eighteen, the judge slammed him: over a hundred consecutive years for what (in Baltimore at least) would have been a ten year sentence, max. When he was first considered for parole, the board would have granted him parole only under one condition (a "firm" condition, as handwritten onto the parole document): that he leave the state. This was not your average offender.

He asked to have his sentence reconsidered, and was granted a reduction by a new judge who noted that she didn't understand why he had been given so much time. (There was no discussion of the reasoning behind this decision other than that the sentence seemed excessive. No discussion of his previous offenses or the nature of the index crimes.) The state's attorney's office opposed his parole each time it came up (then again, that's their job).

When he petitioned Governor Huckabee for a commutation he admitted that he had some initial adjustment problems (he didn't mention what they were, but I could make an educated guess) but added that since his mother died he was determined to turn his life around. He denied any history of alcohol or drug abuse or any history of psychiatric illness or treatment. According the Examiner.com web site, he never required mental health care during the eleven years in prison. When he got out and moved to Washington he was able to run his own landscaping business and get married. A pretty good start, even without therapy.

Prior to killing the police, Clemmons exhibited unusual behavior: claiming to be Jesus, to be able to fly, and forcing his family to undress. To put it modestly, this was a bit of a change for him. He might have been violent and antisocial in the past, but he was never known to be "crazy".

The general public will never know the full story behind the change in his mental state since he was killed by police. Had he survived, he likely would have received a thorough and detailed pretrial psychiatric evaluation for an insanity defense. Only then would we have found out if he really had a psychotic disorder or if he was psychotic due to PCP, Ecstacy or crack cocaine use.

Could any of this have been prevented? I don't know. Maybe, if his sentence hadn't been reduced, both he and the four police officers might be alive today. Then again, maybe he could have been killed (or murdered someone else) in prison. We'll never know.